Is Freehand Technique of Pedicle Screw Insertion in Thoracolumbar Spine Safe and Accurate? Assessment of 250 Screws

Abstract

Background: Pedicle screw fixation is one of the widely used procedures for instrumentation and stabilization of the thoracic and lumbar spine. It has the advantage of stabilizing all the three columns in single approach. Various assistive techniques are available to place the pedicle screws more accurately but at the expense of increased exposure to radiation, prolonged surgical duration, and cost. Objective: The objective of this study is to determine the accuracy and safety of pedicle screw fixation in the thoracolumbar spine using freehand surgical technique. Materials and Methods: We evaluated all patients who underwent pedicle screw fixation of the thoracolumbar spine for various ailments at our institute from January 2016 to December 2017 with postoperative computed tomography scan for placement accuracy. We used Gertzbein classification to grade pedicle breaches. Screw penetration more than 4 mm was taken as critical and those less than that were classified as noncritical. Results: A total of 256 screws inserted in T1–L5 vertebrae were included from 40 consecutive patients. Six screws were excluded according to selection criteria. The mean age was 39 years. Trauma (36 patients) was the common reason for which the pedicle screw fixation was done followed by degenerative disease (2 patients) and tumour (2 patients). A total of ten pedicle screw breaches (4%) were identified in eight patients. Among these, three critical breaches (1.2%) were occurred in two patients which required revision. The remaining seven breaches were noncritical and kept under close observation and follow-up. Conclusion: Pedicle screw had become the workhorse of posterior stabilization of the spine. Based on external anatomy and landmarks alone, freehand technique for pedicle screw fixation can be performed with acceptable safety and accuracy avoiding cumulative radiation exposure and prolonged operative time.

Breach Rate Analysis of Pedicle Screw Instrumentation using Free-Hand Technique in the Surgical Correction of Adolescent Idiopathic Scoliosis

“…However, compared to others, free-hand techniques are less expensive and less complex, with less radiation exposure to both patient and surgeon and less intraoperative time [ 8 ]. Moreover, based on previous researches, free-hand technique has an acceptable safety and accuracy [ 9 ]. We performed this study to answer five questions regarding the safety and the accuracy of free-hand technique during pedicle screw instrumentation.…”

A case series of eight scoliosis patients undergone pedicle screw placement with freehand technique: study for safety and accuracy

“…1,5 Freehand technique in an experienced surgeon simplifies the process of pedicle screw insertion and speeds up surgical procedure, and there is no risk of radiation exposure. 1,2,8 In a metaanalysis, Tian et al¹ investigated the accuracy of pedicle screw insertion in various spinal diseases with various methods and they found that navigated technique was more accurate along with similar clinical outcomes. AIS patients are mostly teenager and unnecessary radiation exposure during surgery need to be avoided for their good quality of life in the future.…”

“…1,3,5 Malposition of a pedicle screw could violate the spinal cortex, causing neurological and vascular complications. 1,2 Owing to financial reasons, a lack of equipment, and radiation safety for medical personnel and patient, our institution adopted the freehand technique. The pedicle screw insertion of thoracic and lumbar spine in this technique is guided by anatomical marker only instead of fluoroscopy.…”

“…Its safety has been proven by several published studies. 1,2 In our center, the surgeries were performed by senior spine surgeons. Although our institution has never encountered any neurological and vascular complications of screw violation cases that could jeopardize the patients' safety, we understand the necessity of evaluating a proper screw insertion.…”

Influence of various pilot hole profiles on pedicle screw fixation strength in minimally invasive and traditional spinal surgery: a comparative biomechanical study

“…These two surgical approaches use different methods for inserting pedicle screws. One is the traditional freehand technique ( Karapinar et al, 2008 ; Mattei et al, 2009 ; Vijayeswaran et al, 2019 ; He et al, 2022 ), and the other is the minimally invasive image-guided technique ( Gelalis et al, 2012 ; Lieberman et al, 2020 ; Sun et al, 2020 ; Li et al, 2022 ; Zhang et al, 2023 ). These two techniques also correspond to different pilot hole profiles.…”